Is Attention-Deficit/Hyperactivity Being Overlooked?
A delve into the details of the disorder and how it applies to insurance claims resolution.
The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) contains the diagnostic criteria used in clinical settings. All of the DSM-IV-TR criteria must be present for a diagnosis of ADHD. For a valid diagnosis, a claimant must exhibit the core symptoms of attention problems, hyperactivity/impulsiveness, or both. It is also necessary that:
- Symptoms are present in more than one setting, such as home, school, or work, or in more than one relationship (e.g., parents and grandparents in children, or spouse and coworkers in adults).
- Symptoms result in significant impairment in educational, social, or occupational functioning.
- The core problems have been present for at least six months
- The problems began before seven years of age.
Currently, the DSM system allows for the following diagnostic possibilities:
- Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
- Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
- Attention-Deficit/Hyperactivity Disorder, Combined Type
- Attention-Deficit/Hyperactivity Disorder, Not Otherwise Specified (NOS)
Many people think of ADHD as the latest excuse for selfish and impulsive behavior. In fact, ADHD is not new. It was first described around the start of the 20th century but then was largely lost from view as theories of environmental causes became paramount in the 1920s and dominated into the late 1960s. Then there was a shift away from perceiving children’s problems as merely a reflection of parenting and other situational variables and towards stable “disorders” within the child, often with a contributing genetic or biological cause. The diagnosis of ADHD has been subjected to an enormous amount of scientific scrutiny regarding its reliability and validity as a disorder and the implications for etiology, treatment and prognosis. It has long been established as a legitimate mental disorder.
Heredity is the largest determinant of who will get ADHD. Twin and family studies show that heredity accounts for about 50% of the variance. Children of a parent with ADHD have a 50% likelihood of having ADHD. Among affected children, 8% of biologic parents and only 2% of adoptive parents also had ADHD. The biologic families of ADHD children have high rates of alcoholism, mood disorders, and antisocial personality.
Most recent studies indicate that a majority of children with ADHD will show core symptoms at least through adolescence and about half of the time into adulthood. Approximately 4% to 5% of adults have ADHD, making it one of the most common psychiatric disorders.
In the seventies, ADHD was called “minimal brain dysfunction,” and there is modern evidence that the old label was not far off the mark. An organic neurological disorder involving the frontal lobes and the basal ganglia in the brain also has experimental support.
A recent study combined the findings from 104 measures and 50 standardized tests across 24 studies to determine differences in the neuropsychological functioning of adults with and without ADHD. The largest differences were found for verbal memory, focused attention, sustained attention, abstract verbal problem solving, and working memory. Smaller effects were found for executive functions, visual memory, and visual problem solving. These results are consistent with the hypothesis that the inattention symptoms more so than the hyperactivity symptoms of this disorder persist into adulthood.
- Difficulty completing tasks that require lengthy paperwork and reading
- Ineffective time management
- Difficulty finishing tasks (e.g., multiple partially repaired cars in yard, carpentry projects in house, or garden renovations)
- Frequently loses forms related to claim
- Forgets depositions and teleconferences
- Talks excessively
- Conspicuous finger tapping and foot jiggling
- Risky and adventurous activities during leisure time
- Occupation that requires a frenetic work pace (e.g., cook, ER physician, sales)
- Depression that quickly passes when a specific difficulty is resolved
- Ordinary pressures of life are experienced as repetitive and never-ending crises
- Intrudes on and interrupts others conversations and activities
- Higher than average number of speeding citations, license suspensions, crashes, and crashes involving bodily injury
- Failed attempts to complete vocational and college programs
- Occupational achievement below expectations for intelligence
- Impulsive job changes, major purchases, and long-distance moves
- Interpersonal difficulties in multiple settings due to short-lived relationships or loss of control (e.g., multiple divorces, domestic violence charges)
- Work and home tasks impetuously initiated without a plan for necessary materials, staffing and time
- Low self-esteem
- Abuse of alcohol and other drugs
- Heavy use of legal stimulants (e.g., caffeinated coffee, soda, “power” drinks, caffeine tablets)
- Illegal stimulants (e.g., methamphetamine)
- Use of illicitly acquired prescription stimulant medication (e.g., Ritalin, Adderall)
Though the diagnosis of ADHD in adults depends on verifying that symptoms first appeared in childhood, obtaining childhood recollections and early records is difficult. Reviewing childhood medical and school records is critical. Attempts should be made in any case where an adult claimant is exhibiting the above signs of adult ADHD but alleging that the problems were caused by an insured event that occurred during adulthood.
Reports from persons familiar with the claimant (e.g., spouse, coworkers) will typically contain far more problems than the claimant will report. Outside observers will also often be the best sources of information about comorbid but non-proximally caused mental disorders that affect three of every four adults with ADHD. Mood disorders (major depression, bipolar disorder, and dysthymia), anxiety disorders, substance abuse, personality disorders and learning disabilities are the chief psychiatric comorbidities. Outside observers and pre-morbid medical records will often indicate evidence that signs and symptoms of these disorders long predated the insured event and followed a waxing and waning course that was not appreciably altered by proximally caused injuries.